Provider Demographics
NPI:1972554962
Name:PEDIATRIX MEDICAL GROUP
Entity type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEONATAL NURSE PRACTITONER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:FLAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:RNC, MSN, NNP
Authorized Official - Phone:972-437-5099
Mailing Address - Street 1:3001 E PRESIDENT GEORGE BUSH HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3542
Mailing Address - Country:US
Mailing Address - Phone:972-437-5099
Mailing Address - Fax:
Practice Address - Street 1:3001 E PRESIDENT GEORGE BUSH HWY
Practice Address - Street 2:SUITE 250
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3542
Practice Address - Country:US
Practice Address - Phone:972-437-5099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX676602363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Single Specialty